HF 3

1st Engrossment - 91st Legislature (2019 - 2020) Posted on 03/27/2019 12:46pm

A bill for an act
relating to health care; establishing OneCare Buy-In; establishing outpatient
prescription drug program; modifying provisions governing dental administration;
modifying provisions governing health care; requiring studies and reports; amending
Minnesota Statutes 2018, sections 62J.497, subdivision 1; 256B.0644; 256B.69,
subdivisions 6d, 35; 256B.76, subdivisions 2, 4; 256L.03, by adding a subdivision;
256L.11, subdivision 7; proposing coding for new law in Minnesota Statutes,
chapters 256B; 256L; proposing coding for new law as Minnesota Statutes, chapter
256T; repealing Minnesota Statutes 2018, section 256L.11, subdivision 6a.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2018, section 62J.497, subdivision 1, is amended to read:

Subdivision 1.

Definitions.

(a) For the purposes of this section, the following terms have
the meanings given.

(b) "Backward compatible" means that the newer version of a data transmission standard
would retain, at a minimum, the full functionality of the versions previously adopted, and
would permit the successful completion of the applicable transactions with entities that
continue to use the older versions.

(c) "Dispense" or "dispensing" has the meaning given in section 151.01, subdivision 30.
Dispensing does not include the direct administering of a controlled substance to a patient
by a licensed health care professional.

(d) "Dispenser" means a person authorized by law to dispense a controlled substance,
pursuant to a valid prescription.

(e) "Electronic media" has the meaning given under Code of Federal Regulations, title
45, part 160.103.

(f) "E-prescribing" means the transmission using electronic media of prescription or
prescription-related information between a prescriber, dispenser, pharmacy benefit manager,
or group purchaser, either directly or through an intermediary, including an e-prescribing
network. E-prescribing includes, but is not limited to, two-way transmissions between the
point of care and the dispenser and two-way transmissions related to eligibility, formulary,
and medication history information.

(g) "Electronic prescription drug program" means a program that provides for
e-prescribing.

(h) "Group purchaser" has the meaning given in section 62J.03, subdivision 6 deleted text begin . deleted text end new text begin , excluding
state and federal health care programs under chapters 256B, 256L, and 256T.
new text end

(i) "HL7 messages" means a standard approved by the standards development
organization known as Health Level Seven.

(j) "National Provider Identifier" or "NPI" means the identifier described under Code
of Federal Regulations, title 45, part 162.406.

(k) "NCPDP" means the National Council for Prescription Drug Programs, Inc.

(l) "NCPDP Formulary and Benefits Standard" means the National Council for
Prescription Drug Programs Formulary and Benefits Standard, Implementation Guide,
Version 1, Release 0, October 2005.

(m) "NCPDP SCRIPT Standard" means the National Council for Prescription Drug
Programs Prescriber/Pharmacist Interface SCRIPT Standard, Implementation Guide Version
8, Release 1 (Version 8.1), October 2005, or the most recent standard adopted by the Centers
for Medicare and Medicaid Services for e-prescribing under Medicare Part D as required
by section 1860D-4(e)(4)(D) of the Social Security Act, and regulations adopted under it.
The standards shall be implemented according to the Centers for Medicare and Medicaid
Services schedule for compliance. Subsequently released versions of the NCPDP SCRIPT
Standard may be used, provided that the new version of the standard is backward compatible
to the current version adopted by the Centers for Medicare and Medicaid Services.

(n) "Pharmacy" has the meaning given in section 151.01, subdivision 2.

(o) "Prescriber" means a licensed health care practitioner, other than a veterinarian, as
defined in section 151.01, subdivision 23.

(p) "Prescription-related information" means information regarding eligibility for drug
benefits, medication history, or related health or drug information.

(q) "Provider" or "health care provider" has the meaning given in section 62J.03,
subdivision 8.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2022.
new text end

Sec. 2.

new text begin [256B.0371] ADMINISTRATION OF DENTAL SERVICES.
new text end

new text begin Subdivision 1. new text end

new text begin Contract for dental administration services. new text end

new text begin (a) Effective January 1,
2022, the commissioner shall contract with a dental administrator to administer dental
services for all recipients of medical assistance and MinnesotaCare.
new text end

new text begin (b) The dental administrator must provide administrative services including but not
limited to:
new text end

new text begin (1) provider recruitment, contracting, and assistance;
new text end

new text begin (2) recipient outreach and assistance;
new text end

new text begin (3) utilization management and review for medical necessity of dental services;
new text end

new text begin (4) dental claims processing;
new text end

new text begin (5) coordination with other services;
new text end

new text begin (6) management of fraud and abuse;
new text end

new text begin (7) monitoring of access to dental services;
new text end

new text begin (8) performance measurement;
new text end

new text begin (9) quality improvement and evaluation requirements; and
new text end

new text begin (10) management of third-party liability requirements.
new text end

new text begin (c) Payments to contracted dental providers must be at the rates established under section
256B.76.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2022.
new text end

Sec. 3.

Minnesota Statutes 2018, section 256B.0644, is amended to read:

256B.0644 REIMBURSEMENT UNDER OTHER STATE HEALTH CARE
PROGRAMS.

(a) A vendor of medical care, as defined in section 256B.02, subdivision 7, and a health
maintenance organization, as defined in chapter 62D, must participate as a provider or
contractor in the medical assistance program and MinnesotaCare as a condition of
participating as a provider in health insurance plans and programs or contractor for state
employees established under section 43A.18, the public employees insurance program under
section 43A.316, for health insurance plans offered to local statutory or home rule charter
city, county, and school district employees, the workers' compensation system under section
176.135, and insurance plans provided through the Minnesota Comprehensive Health
Association under sections 62E.01 to 62E.19. The limitations on insurance plans offered to
local government employees shall not be applicable in geographic areas where provider
participation is limited by managed care contracts with the Department of Human Services.
This section does not apply to dental service providers providing dental services outside
the seven-county metropolitan area.

(b) For providers other than health maintenance organizations, participation in the medical
assistance program means that:

(1) the provider accepts new medical assistance and MinnesotaCare patients;

(2) for providers other than dental service providers, at least 20 percent of the provider's
patients are covered by medical assistance and MinnesotaCare as their primary source of
coverage; or

(3) for dental service providers providing dental services in the seven-county metropolitan
area, at least ten percent of the provider's patients are covered by medical assistance and
MinnesotaCare as their primary source of coverage, or the provider accepts new medical
assistance and MinnesotaCare patients who are children with special health care needs. For
purposes of this section, "children with special health care needs" means children up to age
18 who: (i) require health and related services beyond that required by children generally;
and (ii) have or are at risk for a chronic physical, developmental, behavioral, or emotional
condition, including: bleeding and coagulation disorders; immunodeficiency disorders;
cancer; endocrinopathy; developmental disabilities; epilepsy, cerebral palsy, and other
neurological diseases; visual impairment or deafness; Down syndrome and other genetic
disorders; autism; fetal alcohol syndrome; and other conditions designated by the
commissioner after consultation with representatives of pediatric dental providers and
consumers.

(c) Patients seen on a volunteer basis by the provider at a location other than the provider's
usual place of practice may be considered in meeting the participation requirement in this
section. The commissioner shall establish participation requirements for health maintenance
organizations. The commissioner shall provide lists of participating medical assistance
providers on a quarterly basis to the commissioner of management and budget, the
commissioner of labor and industry, and the commissioner of commerce. Each of the
commissioners shall develop and implement procedures to exclude as participating providers
in the program or programs under their jurisdiction those providers who do not participate
in the medical assistance program. The commissioner of management and budget shall
implement this section through contracts with participating health and dental carriers.

(d) A volunteer dentist who has signed a volunteer agreement under section 256B.0625,
subdivision 9a, shall not be considered to be participating in medical assistance or
MinnesotaCare for the purpose of this section.

new text begin (e) A vendor of medical care, as defined in section 256B.02, subdivision 7, that dispenses
outpatient prescription drugs in accordance with chapter 151 must participate as a provider
or contractor in the MinnesotaCare program as a condition of participating as a provider in
the medical assistance program.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2022.
new text end

Sec. 4.

Minnesota Statutes 2018, section 256B.69, subdivision 6d, is amended to read:

Subd. 6d.

Prescription drugs.

The commissioner deleted text begin may deleted text end new text begin shall new text end exclude deleted text begin or modify deleted text end coverage
for prescription drugs from the prepaid managed care contracts entered into under this
section deleted text begin in order to increase savings to the state by collecting additional prescription drug
rebates. The contracts must maintain incentives for the managed care plan to manage drug
costs and utilization and may require that the managed care plans maintain an open drug
formulary. In order to manage drug costs and utilization, the contracts may authorize the
managed care plans to use preferred drug lists and prior authorization. This subdivision is
contingent on federal approval of the managed care contract changes and the collection of
additional prescription drug rebates deleted text end .

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2022.
new text end

Sec. 5.

Minnesota Statutes 2018, section 256B.69, subdivision 35, is amended to read:

Subd. 35.

Statewide procurement.

(a) For calendar year 2015, the commissioner may
extend a demonstration provider's contract under this section for a sixth year after the most
recent procurement. For calendar year 2015, section 16B.98, subdivision 5, paragraph (b),
and section 16C.05, subdivision 2, paragraph (b), shall not apply to contracts under this
section.

(b) For calendar year 2016 contracts under this section, the commissioner shall procure
through a statewide procurement, which includes all 87 counties, demonstration providers,
and participating entities as defined in section 256L.01, subdivision 7. The commissioner
shall publish a request for proposals by January 5, 2015. As part of the procurement process,
the commissioner shall:

(1) seek each individual county's input;

(2) organize counties into regional groups, and consider single counties for the largest
and most diverse counties; and

(3) seek regional and county input regarding the respondent's ability to fully and
adequately deliver required health care services, offer an adequate provider network, provide
care coordination with county services, and serve special populations, including enrollees
with language and cultural needs.

new text begin (c) For calendar year 2021, the commissioner may extend a demonstration provider's
contract under this section for a sixth year after the most recent procurement, for the provision
of services in the seven-county metropolitan area to families and children under medical
assistance and MinnesotaCare. For calendar year 2021, section 16B.98, subdivision 5,
paragraph (b), and section 16C.06, subdivision 3b, shall not apply to contracts under this
section. For calendar year 2022, the commissioner shall procure services in the seven-county
metropolitan area for families and children under medical assistance and MinnesotaCare,
from demonstration providers and participating entities as defined in section 256L.01,
subdivision 7.
new text end

Sec. 6.

Minnesota Statutes 2018, section 256B.76, subdivision 2, is amended to read:

Subd. 2.

Dental reimbursement.

(a) Effective for services rendered on or after October
1, 1992, the commissioner shall make payments for dental services as follows:

(1) dental services shall be paid at the lower of (i) submitted charges, or (ii) 25 percent
above the rate in effect on June 30, 1992; and

(2) dental rates shall be converted from the 50th percentile of 1982 to the 50th percentile
of 1989, less the percent in aggregate necessary to equal the above increases.

(b) Beginning October 1, 1999, the payment for tooth sealants and fluoride treatments
shall be the lower of (1) submitted charge, or (2) 80 percent of median 1997 charges.

(c) Effective for services rendered on or after January 1, 2000, payment rates for dental
services shall be increased by three percent over the rates in effect on December 31, 1999.

(d) Effective for services provided on or after January 1, 2002, payment for diagnostic
examinations and dental x-rays provided to children under age 21 shall be the lower of (1)
the submitted charge, or (2) 85 percent of median 1999 charges.

(e) The increases listed in paragraphs (b) and (c) shall be implemented January 1, 2000,
for managed care.

(f) Effective for dental services rendered on or after October 1, 2010, by a state-operated
dental clinic, payment shall be paid on a reasonable cost basis that is based on the Medicare
principles of reimbursement. This payment shall be effective for services rendered on or
after January 1, 2011, to recipients enrolled in managed care plans or county-based
purchasing plans.

(g) Beginning in fiscal year 2011, if the payments to state-operated dental clinics in
paragraph (f), including state and federal shares, are less than $1,850,000 per fiscal year, a
supplemental state payment equal to the difference between the total payments in paragraph
(f) and $1,850,000 shall be paid from the general fund to state-operated services for the
operation of the dental clinics.

(h) If the cost-based payment system for state-operated dental clinics described in
paragraph (f) does not receive federal approval, then state-operated dental clinics shall be
designated as critical access dental providers under subdivision 4, paragraph (b), and shall
receive the critical access dental reimbursement rate as described under subdivision 4,
paragraph (a).

(i) Effective for services rendered on or after September 1, 2011, through June 30, 2013,
payment rates for dental services shall be reduced by three percent. This reduction does not
apply to state-operated dental clinics in paragraph (f).

(j) Effective for services rendered on or after January 1, 2014, payment rates for dental
services shall be increased by five percent from the rates in effect on December 31, 2013.
This increase does not apply to state-operated dental clinics in paragraph (f), federally
qualified health centers, rural health centers, and Indian health services. Effective January
1, 2014, payments made to managed care plans and county-based purchasing plans under
sections 256B.69, 256B.692, and 256L.12 shall reflect the payment increase described in
this paragraph.

(k) Effective for services rendered on or after July 1, 2015, through December 31, 2016,
the commissioner shall increase payment rates for services furnished by dental providers
located outside of the seven-county metropolitan area by the maximum percentage possible
above the rates in effect on June 30, 2015, while remaining within the limits of funding
appropriated for this purpose. This increase does not apply to state-operated dental clinics
in paragraph (f), federally qualified health centers, rural health centers, and Indian health
services. Effective January 1, 2016, through December 31, 2016, payments to managed care
plans and county-based purchasing plans under sections 256B.69 and 256B.692 shall reflect
the payment increase described in this paragraph. The commissioner shall require managed
care and county-based purchasing plans to pass on the full amount of the increase, in the
form of higher payment rates to dental providers located outside of the seven-county
metropolitan area.

(l) Effective for services provided on or after January 1, 2017 new text begin , through December 31,
2021 new text end , the commissioner shall increase payment rates by 9.65 percent for dental services
provided outside of the seven-county metropolitan area. This increase does not apply to
state-operated dental clinics in paragraph (f), federally qualified health centers, rural health
centers, or Indian health services. Effective January 1, 2017, payments to managed care
plans and county-based purchasing plans under sections 256B.69 and 256B.692 shall reflect
the payment increase described in this paragraph.

(m) Effective for services provided on or after July 1, 2017 new text begin , through December 31, 2021 new text end ,
the commissioner shall increase payment rates by 23.8 percent for dental services provided
to enrollees under the age of 21. This rate increase does not apply to state-operated dental
clinics in paragraph (f), federally qualified health centers, rural health centers, or Indian
health centers. This rate increase does not apply to managed care plans and county-based
purchasing plans.

new text begin (n) Effective for dental services provided on or after January 1, 2022, the commissioner
shall increase payment rates by 54 percent. This rate increase does not apply to state-operated
dental clinics in paragraph (f), federally qualified health centers, rural health centers, or
Indian health centers.
new text end

Sec. 7.

Minnesota Statutes 2018, section 256B.76, subdivision 4, is amended to read:

Subd. 4.

Critical access dental providers.

(a) The commissioner shall increase
reimbursements to dentists and dental clinics deemed by the commissioner to be critical
access dental providers. For dental services rendered on or after July 1, 2016, new text begin through
December 31, 2021, new text end the commissioner shall increase reimbursement by 37.5 percent above
the reimbursement rate that would otherwise be paid to the critical access dental provider,
except as specified under paragraph (b). The commissioner shall pay the managed care
plans and county-based purchasing plans in amounts sufficient to reflect increased
reimbursements to critical access dental providers as approved by the commissioner.

(b) For dental services rendered on or after July 1, 2016, by a dental clinic or dental
group that meets the critical access dental provider designation under paragraph (d), clause
(4), and is owned and operated by a health maintenance organization licensed under chapter
62D, the commissioner shall increase reimbursement by 35 percent above the reimbursement
rate that would otherwise be paid to the critical access provider.

(c) Critical access dental payments made under paragraph (a) or (b) for dental services
provided by a critical access dental provider to an enrollee of a managed care plan or
county-based purchasing plan must not reflect any capitated payments or cost-based payments
from the managed care plan or county-based purchasing plan. The managed care plan or
county-based purchasing plan must base the additional critical access dental payment on
the amount that would have been paid for that service had the dental provider been paid
according to the managed care plan or county-based purchasing plan's fee schedule that
applies to dental providers that are not paid under a capitated payment or cost-based payment.

(d) The commissioner shall designate the following dentists and dental clinics as critical
access dental providers:

(1) nonprofit community clinics that:

(i) have nonprofit status in accordance with chapter 317A;

(ii) have tax exempt status in accordance with the Internal Revenue Code, section
501(c)(3);

(iii) are established to provide oral health services to patients who are low income,
uninsured, have special needs, and are underserved;

(iv) have professional staff familiar with the cultural background of the clinic's patients;

(v) charge for services on a sliding fee scale designed to provide assistance to low-income
patients based on current poverty income guidelines and family size;

(vi) do not restrict access or services because of a patient's financial limitations or public
assistance status; and

(vii) have free care available as needed;

(2) federally qualified health centers, rural health clinics, and public health clinics;

(3) hospital-based dental clinics owned and operated by a city, county, or former state
hospital as defined in section 62Q.19, subdivision 1, paragraph (a), clause (4);

(4) a dental clinic or dental group owned and operated by a nonprofit corporation in
accordance with chapter 317A with more than 10,000 patient encounters per year with
patients who are uninsured or covered by medical assistance or MinnesotaCare;

(5) a dental clinic owned and operated by the University of Minnesota or the Minnesota
State Colleges and Universities system; and

(6) private practicing dentists if:

(i) the dentist's office is located within the seven-county metropolitan area and more
than 50 percent of the dentist's patient encounters per year are with patients who are uninsured
or covered by medical assistance or MinnesotaCare; or

(ii) the dentist's office is located outside the seven-county metropolitan area and more
than 25 percent of the dentist's patient encounters per year are with patients who are uninsured
or covered by medical assistance or MinnesotaCare.

Sec. 8.

Minnesota Statutes 2018, section 256L.03, is amended by adding a subdivision to
read:

new text begin Subd. 7. new text end

new text begin Outpatient prescription drugs. new text end

new text begin Outpatient prescription drugs are covered
according to section 256L.30. This subdivision applies to all individuals enrolled in the
MinnesotaCare program.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2022.
new text end

Sec. 9.

Minnesota Statutes 2018, section 256L.11, subdivision 7, is amended to read:

Subd. 7.

Critical access dental providers.

Effective for dental services provided to
MinnesotaCare enrollees on or after July 1, 2017 new text begin , through December 31, 2021 new text end , the
commissioner shall increase payment rates to dentists and dental clinics deemed by the
commissioner to be critical access providers under section 256B.76, subdivision 4, by 20
percent above the payment rate that would otherwise be paid to the provider. The
commissioner shall pay the prepaid health plans under contract with the commissioner
amounts sufficient to reflect this rate increase. The prepaid health plan must pass this rate
increase to providers who have been identified by the commissioner as critical access dental
providers under section 256B.76, subdivision 4.

Sec. 10.

new text begin [256L.30] OUTPATIENT PRESCRIPTION DRUGS.
new text end

new text begin Subdivision 1. new text end

new text begin Establishment of program. new text end

new text begin The commissioner shall administer and
oversee the outpatient prescription drug program for MinnesotaCare. The commissioner
shall not include the outpatient pharmacy benefit in a contract with a public or private entity.
new text end

new text begin Subd. 2. new text end

new text begin Covered outpatient prescription drugs. new text end

new text begin (a) In consultation with the Drug
Formulary Committee under section 256B.0625, subdivision 13d, the commissioner shall
establish an outpatient prescription drug formulary for MinnesotaCare that satisfies the
requirements for an essential health benefit under Code of Federal Regulations, title 45,
section 156.122. The commissioner may modify the formulary after consulting with the
Drug Formulary Committee and providing public notice and the opportunity for public
comment. The commissioner is exempt from the rulemaking requirements of chapter 14 to
establish the drug formulary, and section 14.386 does not apply. The commissioner shall
make the drug formulary available to the public on the agency website.
new text end

new text begin (b) The MinnesotaCare formulary must contain at least one drug in every United States
Pharmacopeia category and class or the same number of prescription drugs in each category
and class as the essential health benefit benchmark plan, whichever is greater.
new text end

new text begin (c) The commissioner may negotiate drug rebates or discounts directly with a drug
manufacturer to place a drug on the formulary. The commissioner may also negotiate drug
rebates, or discounts, with a drug manufacturer through a contract with a vendor. The
commissioner, beginning January 15, 2022, and each January 15 thereafter, shall notify the
chairs and ranking minority members of the legislative committees with jurisdiction over
health and human services policy and finance of the rebates and discounts negotiated, their
aggregate dollar value, and how the department applied these savings, including the extent
to which these savings were passed on to enrollees.
new text end

new text begin (d) Prior authorization may be required by the commissioner before certain formulary
drugs are eligible for payment. The Drug Formulary Committee may recommend drugs for
prior authorization directly to the commissioner. The commissioner may also request that
the Drug Formulary Committee review a drug for prior authorization.
new text end

new text begin (e) Before the commissioner requires prior authorization for a drug:
new text end

new text begin (1) the commissioner must provide the Drug Formulary Committee with information
on the impact that placing the drug on prior authorization may have on the quality of patient
care and on program costs and information regarding whether the drug is subject to clinical
abuse or misuse if such data is available; and
new text end

new text begin (2) the Drug Formulary Committee must hold a public forum and receive public comment
for an additional 15 days from the date of the public forum.
new text end

new text begin (f) Notwithstanding paragraph (e), the commissioner may automatically require prior
authorization for a period not to exceed 180 days for any drug that is approved by the United
States Food and Drug Administration after July 1, 2019. The 180-day period begins no later
than the first day that a drug is available for shipment to pharmacies within the state. The
Drug Formulary Committee shall recommend to the commissioner general criteria to use
for determining prior authorization of the drugs, but the Drug Formulary Committee is not
required to review each individual drug.
new text end

new text begin (g) The commissioner may also require prior authorization before nonformulary drugs
are eligible for payment.
new text end

new text begin (h) Prior authorization requests must be processed in accordance with Code of Federal
Regulations, title 45, section 156.122.
new text end

new text begin Subd. 3. new text end

new text begin Pharmacy provider participation. new text end

new text begin (a) A pharmacy enrolled to dispense
prescription drugs to medical assistance enrollees under section 256B.0625 must participate
as a provider in the MinnesotaCare outpatient prescription drug program.
new text end

new text begin (b) A pharmacy that is enrolled to dispense prescription drugs to MinnesotaCare enrollees
is not permitted to refuse service to an enrollee unless:
new text end

new text begin (1) the pharmacy does not have a prescription drug in stock and cannot obtain the drug
in time to treat the enrollee's medical condition;
new text end

new text begin (2) the enrollee is unable or unwilling to pay the enrollee's co-payment at the time the
drug is dispensed;
new text end

new text begin (3) after performing drug utilization review, the pharmacist identifies the prescription
drug as being a therapeutic duplication, having a drug-disease contraindication, having a
drug-drug interaction, having been prescribed for the incorrect dosage or duration of
treatment, having a drug-allergy interaction, or having issues related to clinical abuse or
misuse by the enrollee;
new text end

new text begin (4) the prescription drug is not covered by MinnesotaCare; or
new text end

new text begin (5) dispensing the drug would violate a provision of chapter 151.
new text end

new text begin Subd. 4. new text end

new text begin Covered outpatient prescription drug reimbursement rate. new text end

new text begin (a) The basis
for determining the amount of payment shall be the lowest of the National Average Drug
Acquisition Cost, plus a fixed dispensing fee; the maximum allowable cost established
under section 256B.0625, subdivision 13e, plus a fixed dispensing fee; or the usual and
customary price. The fixed dispensing fee shall be $1.50 for covered outpatient prescription
drugs.
new text end

new text begin (b) The basis for determining the amount of payment for a pharmacy that acquires drugs
through the federal 340B Drug Pricing Program shall be the lowest of:
new text end

new text begin (1) the National Average Drug Acquisition Cost minus 30 percent;
new text end

new text begin (2) the maximum allowable cost established under section 256B.0625, subdivision 13e,
minus 30 percent, plus a fixed dispensing fee; or
new text end

new text begin (3) the usual and customary price. The fixed dispensing fee shall be $1.50 for covered
outpatient prescription drugs.
new text end

new text begin (c) For purposes of this subdivision, the usual and customary price is the lowest price
charged by the provider to a patient who pays for the prescription by cash, check, or charge
account and includes the prices the pharmacy charges to customers enrolled in a prescription
savings club or prescription discount club administered by the pharmacy, pharmacy chain,
or contractor to the provider.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2022.
new text end

Sec. 11.

new text begin [256T.01] DEFINITIONS.
new text end

new text begin Subdivision 1. new text end

new text begin Application. new text end

new text begin For purposes of this chapter, the terms in this section have
the meanings given.
new text end

new text begin Subd. 2. new text end

new text begin Commissioner. new text end

new text begin "Commissioner" means the commissioner of human services.
new text end

new text begin Subd. 3. new text end

new text begin Department. new text end

new text begin "Department" means the Department of Human Services.
new text end

new text begin Subd. 4. new text end

new text begin Essential health benefits. new text end

new text begin "Essential health benefits" has the meaning given
in section 62Q.81, subdivision 4.
new text end

new text begin Subd. 5. new text end

new text begin Individual market. new text end

new text begin "Individual market" has the meaning given in section
62A.011, subdivision 5.
new text end

new text begin Subd. 6. new text end

new text begin MNsure website. new text end

new text begin "MNsure website" has the meaning given in section 62V.02,
subdivision 13.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 12.

new text begin [256T.02] ONECARE BUY-IN.
new text end

new text begin Subdivision 1. new text end

new text begin Establishment. new text end

new text begin (a) The commissioner shall establish a program consistent
with this section to offer products developed for the OneCare Buy-In through the MNsure
website.
new text end

new text begin (b) The commissioner, in collaboration with the commissioner of commerce and the
MNsure Board, shall:
new text end

new text begin (1) establish a cost allocation methodology to reimburse MNsure operations in lieu of
the premium withhold for qualified health plans under section 62V.05;
new text end

new text begin (2) implement mechanisms to ensure the long-term financial sustainability of Minnesota's
public health care programs and mitigate any adverse financial impacts to the state and
MNsure. These mechanisms must minimize adverse selection, state financial risk and
contribution, and negative impacts to premiums in the individual and group health insurance
markets; and
new text end

new text begin (3) coordinate eligibility, coverage, and provider networks to ensure that persons, to the
extent possible, transitioning between medical assistance, MinnesotaCare, and the OneCare
Buy-In have continuity of care.
new text end

new text begin (c) The OneCare Buy-In shall be considered:
new text end

new text begin (1) a public health care program for purposes of chapter 62V; and
new text end

new text begin (2) the MinnesotaCare program for purposes of requirements for health maintenance
organizations under section 62D.04, subdivision 5, and providers under section 256B.0644.
new text end

new text begin (d) The Department of Human Services is deemed to meet and receive certification and
authority under section 62D.03 and be in compliance with sections 62D.01 to 62D.30. The
commissioner has the authority to accept and expend all federal funds made available under
this chapter upon federal approval.
new text end

new text begin Subd. 2. new text end

new text begin Premium administration and payment. new text end

new text begin (a) The commissioner shall establish
annually a per-enrollee monthly premium rate. The commissioner shall publish the premium
rate by August 1 of each year.
new text end

new text begin (b) OneCare Buy-In premium administration shall be consistent with requirements under
the federal Affordable Care Act for qualified health plan premium administration. Premium
rates shall be established in accordance with section 62A.65, subdivision 3.
new text end

new text begin Subd. 3. new text end

new text begin Rates to providers. new text end

new text begin The commissioner shall establish rates for provider
payments that are targeted to the current rates established under chapter 256L, plus the
aggregate difference between those rates and Medicare rates. The aggregate must not consider
services that receive a Medicare encounter payment.
new text end

new text begin Subd. 4. new text end

new text begin Reserve and other financial requirements. new text end

new text begin (a) A OneCare Buy-In reserve
account is established in the state treasury. Enrollee premiums collected under subdivision
2 shall be deposited into the reserve account. The reserve account shall be used to cover
expenditures related to operation of the OneCare Buy-In, including the payment of claims
and all other accrued liabilities. No other account within the state treasury shall be used to
finance the reserve account except as otherwise specified in state law.
new text end

new text begin (b) Beginning January 1, 2023, enrollee premiums shall be set at a level sufficient to
fund all ongoing claims costs and all ongoing costs necessary to manage the program and
support ongoing maintenance of information technology systems and operational and
administrative functions of the OneCare Buy-In program.
new text end

new text begin (c) The commissioner is prohibited from expending state dollars beyond what is
specifically appropriated in law, or transferring funds from other accounts, in order to fund
the reserve account, fund claims costs, or support ongoing administration and operation of
the program and its information technology systems.
new text end

new text begin Subd. 5. new text end

new text begin Covered benefits. new text end

new text begin Each health plan established under this chapter must include
the essential health benefits package required under section 1302(a) of the Affordable Care
Act and as described in section 62Q.81; dental services described in section 256B.0625,
subdivision 9, paragraphs (b) and (c); and vision services described in Minnesota Rules,
part 9505.0277, and may include other services under section 256L.03, subdivision 1.
new text end

new text begin Subd. 6. new text end

new text begin Third-party administrator. new text end

new text begin (a) The commissioner may enter into a contract
with a third-party administrator to perform the operational management of the OneCare
Buy-In. Duties of the third-party administrator include but are not limited to the following:
new text end

new text begin (1) development and distribution of plan materials for potential enrollees;
new text end

new text begin (2) receipt and processing of electronic enrollment files sent from the state;
new text end

new text begin (3) creation and distribution of plan enrollee materials including identification cards,
certificates of coverage, a plan formulary, a provider directory, and premium billing
statements;
new text end

new text begin (4) processing premium payments and sending termination notices for nonpayment to
enrollees and the state;
new text end

new text begin (5) payment and adjudication of claims;
new text end

new text begin (6) utilization management;
new text end

new text begin (7) coordination of benefits;
new text end

new text begin (8) grievance and appeals activities; and
new text end

new text begin (9) fraud, waste, and abuse prevention activities.
new text end

new text begin (b) Any solicitation of vendors to serve as the third-party administrator is subject to the
requirements under section 16C.06.
new text end

new text begin Subd. 7. new text end

new text begin Eligibility. new text end

new text begin (a) To be eligible for the OneCare Buy-In, a person must:
new text end

new text begin (1) be a resident of Minnesota; and
new text end

new text begin (2) not be eligible for government-sponsored programs as defined in United States Code,
title 26, section 5000A(f)(1)(A). For purposes of this subdivision, an applicant or enrollee
who is entitled to Medicare Part A or enrolled in Medicare Part B coverage under title XVIII
of the Social Security Act, United States Code, title 42, sections 1395c to 1395w-152, is
considered eligible for government-sponsored programs. An applicant or enrollee who is
entitled to premium-free Medicare Part A shall not refuse to apply for or enroll in Medicare
coverage to establish eligibility for the OneCare Buy-In.
new text end

new text begin (b) A person who is determined eligible for enrollment in a qualified health plan with
or without advance payments of the premium tax credit and with or without cost-sharing
reductions according to Code of Federal Regulations, title 45, section 155.305, paragraphs
(a), (f), and (g), is eligible to purchase and enroll in the OneCare Buy-In instead of purchasing
a qualified health plan as defined under section 62V.02.
new text end

new text begin Subd. 8. new text end

new text begin Enrollment. new text end

new text begin (a) A person may apply for the OneCare Buy-In during the annual
open and special enrollment periods established for MNsure as defined in Code of Federal
Regulations, title 45, sections 155.410 and 155.420, through the MNsure website.
new text end

new text begin (b) A person must annually reenroll for the OneCare Buy-In during open and special
enrollment periods.
new text end

new text begin Subd. 9. new text end

new text begin Premium tax credits, cost-sharing reductions, and subsidies. new text end

new text begin A person who
is eligible under this chapter, and whose income is less than or equal to 400 percent of the
federal poverty guidelines, may qualify for advance premium tax credits and cost-sharing
reductions under Code of Federal Regulations, title 45, section 155.305, paragraphs (a), (f),
and (g), to purchase a health plan established under this chapter.
new text end

new text begin Subd. 10. new text end

new text begin Covered benefits and payment rate modifications. new text end

new text begin The commissioner, after
providing public notice and an opportunity for public comment, may modify the covered
benefits and payment rates to carry out this chapter.
new text end

new text begin Subd. 11. new text end

new text begin Coverage for legislators. new text end

new text begin Effective upon the availability of coverage through
the OneCare Buy-in program, all members of the state legislature shall be eligible for health
coverage through that program, and shall not be eligible for coverage offered under section
43A.24.
new text end

new text begin Subd. 12. new text end

new text begin Request for federal authority. new text end

new text begin The commissioner shall seek all necessary
federal waivers to establish the OneCare Buy-In under this chapter.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin (a) Subdivisions 1 to 11 are effective January 1, 2023.
new text end

new text begin (b) Subdivision 12 is effective the day following final enactment.
new text end

Sec. 13.

new text begin [256T.03] ONECARE BUY-IN PRODUCTS.
new text end

new text begin Subdivision 1. new text end

new text begin Platinum product. new text end

new text begin The commissioner of human services shall establish
a OneCare Buy-In coverage option that provides platinum level of coverage in accordance
with the Affordable Care Act and benefits that are actuarially equivalent to 90 percent of
the full actuarial value of the benefits provided under the OneCare Buy-In coverage option.
This product must be made available in all rating areas in the state.
new text end

new text begin Subd. 2. new text end

new text begin Silver and gold products. new text end

new text begin (a) If any rating area lacks an affordable or
comprehensive health care coverage option according to standards developed by the
commissioner of health, the following year the commissioner of human services shall offer
silver and gold products established under paragraph (b) in the rating area for a five-year
period. Notwithstanding section 62U.04, subdivision 11, the commissioner of health may
use data collected under section 62U.04, subdivisions 4 and 5, to monitor triggers in the
individual market under this chapter. Effective January 1, 2020, the commissioner of health
may require submission of additional data elements under section 62U.04, subdivisions 4
and 5, in a manner specified by the commissioner, to conduct the analysis necessary to
monitor the individual market under this chapter.
new text end

new text begin (b) The commissioner shall establish the following OneCare Buy-In coverage options:
one coverage option shall provide silver level of coverage in accordance with the Affordable
Care Act and benefits that are actuarially equivalent to 70 percent of the full actuarial value
of the benefits provided under the OneCare Buy-In coverage option, and one coverage
option shall provide gold level of coverage in accordance with the Affordable Care Act and
benefits that are actuarially equivalent to 80 percent of the full actuarial value of the benefits
provided under the OneCare Buy-In coverage option.
new text end

new text begin Subd. 3. new text end

new text begin Qualified health plan rules. new text end

new text begin (a) The coverage options developed under this
section are subject to the process under section 62K.06. The coverage options developed
under this section are deemed to meet requirements of chapters 62A, 62K, and 62V that
apply to qualified health plans.
new text end

new text begin (b) Notwithstanding any other law to the contrary, benefits under this section are
secondary to a plan of insurance or benefit program under which an eligible person may
have coverage. The commissioner shall use cost-avoidance techniques to coordinate any
other health coverage for eligible persons and identify eligible persons who may have
coverage or benefits under other plans of insurance.
new text end

new text begin (c) The Department of Human Services is not an insurance company for purposes of
this chapter.
new text end

new text begin Subd. 4. new text end

new text begin Actuarial value. new text end

new text begin Determination of the actuarial value of coverage options under
this section must be calculated in accordance with Code of Federal Regulations, title 45,
section 156.135.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2023.
new text end

Sec. 14.

new text begin [256T.04] OUTPATIENT PRESCRIPTION DRUGS.
new text end

new text begin Subdivision 1. new text end

new text begin Establishment of program. new text end

new text begin The commissioner shall administer and
oversee the outpatient prescription drug program for the OneCare Buy-In program. The
commissioner shall not include the outpatient pharmacy benefit in a contract with a public
or private entity.
new text end

new text begin Subd. 2. new text end

new text begin Covered outpatient prescription drugs. new text end

new text begin Outpatient prescription drugs are
covered in accordance with chapter 256L.
new text end

new text begin Subd. 3. new text end

new text begin Pharmacy provider participation. new text end

new text begin Pharmacy provider participation shall be
governed by section 256L.30, subdivision 3.
new text end

new text begin Subd. 4. new text end

new text begin Reimbursement rate. new text end

new text begin The commissioner shall establish outpatient prescription
drug reimbursement rates according to chapter 256L.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2023.
new text end

Sec. 15. new text begin DIRECTION TO COMMISSIONER; STATE-BASED RISK ADJUSTMENT
ANALYSIS.
new text end

new text begin The commissioner of commerce, in consultation with the commissioner of health, shall
conduct a study on the design and implementation of a state-based risk adjustment program.
The commissioner shall report on the findings of the study and any recommendations to
the chairs and ranking minority members of the legislative committees with jurisdiction
over the individual health insurance market by February 15, 2021.
new text end

Sec. 16. new text begin STUDY OF MINNESOTACARE EXPANSION.
new text end

new text begin The commissioner of human services shall study the costs and requirements for a
MinnesotaCare expansion that would:
new text end

new text begin (1) provide individual and small group health coverage with covered benefits and a
provider network equivalent to MinnesotaCare, and enrollee out-of-pocket costs that are
no higher than under MinnesotaCare;
new text end

new text begin (2) contract directly with all health care providers willing to participate and accept
reimbursement and other contract terms;
new text end

new text begin (3) use a single third-party administrator, or be administered directly by the commissioner
of human services;
new text end

new text begin (4) reimburse health care providers at rates no lower than those used under Medicare,
except that the commissioner of human services may negotiate global budgets with health
care providers to control costs and improve the quality of care;
new text end

new text begin (5) maximize federal financial participation, including capturing funding currently
available for premium tax credits to reduce premium costs for enrollees;
new text end

new text begin (6) charge premiums on a sliding scale using an affordability standard, and state-funded
tax credits for persons whose costs exceed the standard; and
new text end

new text begin (7) be available in every Minnesota county.
new text end

new text begin The commissioner of human services shall contract with an actuarial consulting firm to
provide technical assistance in conducting the MinnesotaCare expansion study. The
commissioner of human services shall present a report, implementation plan, and draft
legislation to the chairs and ranking minority members of the legislative committees with
jurisdiction over health and human services policy and finance and health insurance by
December 15, 2019.
new text end

Sec. 17. new text begin STUDY OF COST OF PROVIDING DENTAL SERVICES.
new text end

new text begin The commissioner of human services shall contract with a vendor to conduct a survey
of the cost to Minnesota dental providers of delivering dental services to medical assistance
and MinnesotaCare enrollees under both fee-for-service and managed care. The commissioner
of human services shall ensure that the vendor has prior experience in conducting surveys
of the cost of providing health care services. Each dental provider enrolled with the
department must respond to the cost of service survey. The commissioner of human services
may sanction a dental provider under Minnesota Statutes, section 256B.064, for failure to
respond. The commissioner of human services shall require the vendor to measure statewide
and regional costs for both fee-for-service and managed care, by major dental service
category and for the most common dental services. The commissioner of human services
shall post a copy of the final survey report on the department's website. The initial survey
must be completed no later than January 1, 2021, and the survey must be repeated every
three years. The commissioner of human services shall provide a summary of the results of
each cost of dental services survey and provide recommendations for any changes to dental
payment rates to the chairs and ranking members of the legislative committees with
jurisdiction over health and human services policy and finance.
new text end

Sec. 18. new text begin REPEALER.
new text end

new text begin Minnesota Statutes 2018, section 256L.11, subdivision 6a, new text end new text begin is repealed.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2022.
new text end

APPENDIX

Repealed Minnesota Statutes: H0003-1

256L.11 PROVIDER PAYMENT.

Subd. 6a.

Dental providers.

Effective for dental services provided to MinnesotaCare enrollees on or after January 1, 2018, the commissioner shall increase payment rates to dental providers by 54 percent. Payments made to prepaid health plans under section 256L.12 shall reflect the payment increase described in this subdivision. The prepaid health plans under contract with the commissioner shall provide payments to dental providers that are at least equal to a rate that includes the payment rate specified in this subdivision, and if applicable to the provider, the rates described under subdivision 7.